Prosthetic rehabilitation of geriatric amputee patients: a follow-up study

During a four-year period, 116 lower extremity amputee patients older than 65 years were evaluated and treated by our department. Fifty-nine patients with below-knee (BK) amputations, 22 with above-knee (AK) amputations, and 15 with bilateral amputations were fitted with prostheses and trained in their use. A follow-up study on all patients was done at an average of 22 months after they had completed their training program but not earlier than after 6 months. Of all BK amputees who had been fitted with a prosthesis, 73% were using it fulltime and as their main mode of locomotion; 25% were using it part of the time. The results were less favorable for AK and for bilateral amputee patients: 50% of AK amputees and 33% of the bilateral amputees had become fulltime users of their prostheses. Age alone was not a major determining factor in success or failure of prosthetic rehabilitation. Failures usually were due to concurrent medical disease or mental deterioration. The study indicates that the effort and expense of fitting and training geriatric patients with prostheses may be well worthwhile.     

Biomechanical analysis of the influence of prosthetic feet on below-knee amputee walking

Although energy storing prosthetic feet have achieved widespread clinical acceptance, the effect of these components on the biomechanics of below-knee amputee gait is poorly understood. The purpose of this study was to determine the biomechanical adaptations used by the below-knee amputee while wearing a conventional prosthetic foot and to assess the influence of energy storing prosthetic feet on these adaptations. Mechanical power outputs of the lower extremity in five normal and five below-knee amputee subjects using the SACH, Seattle and Flex feet were studied. Ground reaction forces and kinematic data were collected at a walking speed of 1.5 m/s and were used to determine the muscular power outputs of the lower extremity during stance. Consistent patterns of muscular power output at the hip and knee of the residual limb occur. While wearing the SACH foot, negligible energy generation occurs at the prosthetic foot during pushoff. A decrease in energy absorption at the knee during the first half of stance and an increase in energy generation by the hip extensors were the major adaptations noted in the proximal muscle groups. Compared to the SACH foot, the energy storing feet demonstrated increased energy generation during pushoff. Despite the improvements in the performance of the energy storing prosthetic feet, no significant differences were found in the pattern or magnitude of knee and hip power outputs compared to the SACH foot.     

Acquired limb loss in patients with traumatic brain injury

The outcome associated with long-term prosthetic use was evaluated in 12 patients who had a dual disability of severe traumatic brain injury and an extremity amputation. The incidence and nature of complications after limb loss was also reviewed. The 12 patients sustained 15 extremity amputations. Lower extremity amputations were the most common disability. Fifty percent of the patients had at least one postoperative complication after amputation. All patients (100%) had at least one complication documented on rehabilitation admission. No patient was using a prosthesis at the time of rehabilitation admission. At discharge six patients were able to use a prosthesis. Only one patient was considered independent. Patient follow-up averaged 28.6 months. At long-term follow-up six patients were using a prosthesis. Four were considered independent. One-third of the total group was considered able to use the prosthesis independently in the community. Of the lower extremity amputated population, only 40% became ambulatory. This is considerably less than can be expected to become ambulatory if there was no amputation. All three upper extremity amputees did not use a prosthesis. All efforts should be directed at salvaging a limb threatened by amputation after survival of traumatic brain injury. Early transfer to a facility specializing in traumatic brain injury rehabilitation may decrease complications, reduce total hospitalization and improve overall functional ability.     

Amputation: energy cost of ambulation.

A mobile instrument system was used to measure energy consumption by indirect calorimetry at rest and during ambulation in 25 unimpaired subjects, 6 unilateral below-knee (BK) amputee patients, 6 unilateral above-knee (AK) amputee patients and 4 bilateral AK amputee patients. To prevent the introduction of gait difficulties among the impaired subjects, each subject was permitted to walk at his own comfortable speed. Since speed thus varied among subjects, ambulation data were expressed in units of energy per foot traveled. Statistical analyses of the mean oxygen costs indicated several significant differences among the groups. In comparison to unimpaired subjects, the mean oxygen consumption was 9% higher in unilateral BK amputee patients, 49% higher in unilateral AK amputee patients and 280% higher in bilateral AK amputee patients.     

The 2-minute walk test as a measure of functional improvement in persons with lower limb amputation

OBJECTIVE: To determine the construct validity and responsiveness of the 2-minute walk test as a measure of function in individuals with lower extremity amputation. DESIGN: The distances walked in 2 minutes were compared with the results on the physical functioning subscale of the Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36) and the Houghton Scale. SETTING: Regional amputee rehabilitation program. PATIENTS: Retrospective data from 290 patients (mean age, 66yr) with unilateral transtibial, unilateral transfemoral, or bilateral amputations. INTERVENTION: Repeated testing. MAIN OUTCOME MEASURES: Distance walked in 2 minutes, SF-36 (aggregated into physical and mental composite scores), and the Houghton score. We also examined the change in the distance before and after a rehabilitation program. RESULTS: The distance walked in 2 minutes showed a weak correlation with the physical functioning subscale of the SF-36 (r = .22, p = .008) and a moderate correlation with the total Houghton score at discharge from rehabilitation (r = .493, p 相似文献   

Prosthetic rehabilitation in bilateral high above elbow amputation

Rehabilitation in patients with bilateral high above elbow amputation presents a considerable prosthetic problem. A patient with high upper arm amputations after a high-voltage injury is presented. He was successfully fitted with multifunctional myoelectric hand prostheses. The problems in rehabilitation of adult bilateral arm amputees are discussed and the value of fitting these patients with electrically powered prostheses is assessed. The balance between technical and clinical aspects is discussed in relation to patient acceptance. In our case good acceptance and functional benefit was noted. The fact is stressed that the bilateral upper extremity amputee can regain considerable physical function with the fitting of suitable prostheses, even if the limb remnants are short and provide little or no function. An extensive team approach at specialized centres will favour the results.     

Bilateral below-knee amputations: experience with 80 patients

This review expands information concerning the bilateral below-knee (BK) amputee, describing the findings of a retrospective assessment of 80 such patients. Factors evaluated included etiology, associated conditions, time between amputations, late revisions, use of prostheses, and survival. In 63 patients both amputations were because of atherosclerosis. Of these patients, 86% were diabetic and 84% hypertensive. Peak incidence of the second amputation was during the 7th decade. Average time between amputations was 23 months. Forty-five (71%) of the atherosclerotic patients achieved some functional use of bilateral prostheses. The five patients employed at the time of the second amputation returned to work using prostheses. Average survival after the second amputation was 44 months for those deceased, and 64 months for those alive at the end of the study period. Nine patients had amputations because of various forms of injury, including one for sequential developments due to alcohol-related sensory loss. Eight of this group had a diagnosis of alcohol abuse of psychosis. Reasons for amputations included frostbite, burns, suicide attempt and sensory loss. Five achieved long-term but generally suboptimal prostheses use. The findings support the impression that most atherosclerotic bilateral BK amputees can use prostheses and that their survival and low rate of late stump revisions justify restorative efforts. Mental status was the major determinant of amputation and prostheses use among the non-atherosclerotic patients; discharge from psychiatric hospitals without adequate community support systems was probably contributory. Management and prevention require close collaboration between the rehabilitation, surgical, psychosocial, and public health disciplines.     

Preliminary evaluation of an automatically stance-phase controlled pediatric prosthetic knee joint using quantitative gait analysis

OBJECTIVES: To evaluate the effects on gait of a new pediatric prosthetic knee joint using an automatic stance-phase lock (ASPL), shown previously to help prevent falls, and to propose future design considerations and prosthetic alignments. DESIGN: Case series and crossover trial. SETTING: Human movement laboratory. PARTICIPANTS: Three children with unilateral above-knee amputations and 3 children with bilateral above-knee or below-knee amputations. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Spatiotemporal, kinematic, and kinetic gait parameters. RESULTS: Spatiotemporal parameters indicated higher gait velocities with the ASPL knee joint for the children with unilateral amputations. The increased speed, as expected, was associated with increased temporal interlimb asymmetry, joint moments and powers, and excessive prosthetic knee range of motion in swing. A trend toward increased pelvic motions was observed with ASPL knee when compared with conventional knees. CONCLUSIONS: The biomechanic performance of the single-axis ASPL knee joint was shown to be comparable with more complex polycentric pediatric prosthetic knee joint technologies worn by the children in this study.     

Bilateral lower extremity dressing frame.

Completely independent application of lower extremity prostheses and clothing is essential but often difficult to accomplish in optimal rehabilitation of the bilateral above-knee amputee. This paper suggests an occupational therapy treatment plan for above-knee amputations, discusses reasons for dependency and decreased use of lower extremity prostheses and clothing, and describes a bilateral lower extremity dressing frame designed for independent application of prostheses and lower extremity clothing. The cost of rehabilitation can be justified once independence in application of prostheses and clothing is accomplished and functional ambulation is achieved.     

Treadmill training program for a bilateral below-knee amputee patient with cardiopulmonary disease

This study was undertaken to determine the degree of progress an elderly bilateral below-knee amputee with cardiopulmonary disease could achieve by endurance training on a treadmill. Aspects of medications, orthotic/prosthetic evaluation, and energy expenditure are discussed. The subject was a 63-year-old Class IV cardiac patient with combined restrictive-obstructive pulmonary disease of moderate severity. He had undergone a coronary artery bypass graft (two-vessel) followed by a bilateral below-knee amputation for an ascending dry gangrene. The initial ambulatory aerobic evaluation showed the patient achieving only 50% of predicted maximal heart rate and 20% of maximal oxygen consumption. An individualized daily training program started the patient walking at .5 mph, 0% elevation, for five repetitions at two minutes each. By the end of the six-month training program the workload reached 1.4 mph at 2.5% elevation, for 30 minutes of total external work. The final exercise test evaluation showed an overall increase in age-predicted maximal heart rate (90%) and oxygen consumption (55%). The patient improved from cardiac Class IV to Class II, and therapeutically from Class E (bed rest) to Class C (moderate exercise restriction). These findings suggest a need for endurance training programs for patients with cardiopulmonary disease hindered by additional physical disabilities. The program enabled the participant to engage in significantly higher levels of activity for daily living within the community.     

Joint kinetics in unilateral below-knee amputee patients during running

Objective: To explore the nature of the accommodations in running gait that persons with below-knee amputations make in response to the limb segment loss.Patients: Two groups of volunteer subjects (n = 6 in each group). Individuals in one group had below-knee amputations; the second group had intact lower limbs.Design: Individuals ran at two nominal speeds, 2.7m/sec and 3.5m/sec, over a flush-mounted force platform. Ground reaction force data were combined with simultaneously recorded and subsequently digitized video data of coordinate motion to calculate joint and segment motion and net joint moment data.Results: The degree of left-to-right asymmetry for the amputee group was dependent on the variable of interest. There was symmetry in stride frequency and support moment and a marked asymmetry in ankle, knee, and hip moments. In response to increased running speed, both groups increased the amplitude of each joint moment. The nonamputee group appeared to increase the gain uniformly across the three joints, whereas the intact and prosthetic limbs were not uniformly increased. The temporal sequencing of the components for the intact and prosthetic limbs did not appear to differ from the nonamputee limb. This similarity in timing was unaffected by speed increases.Conclusion: There was no need to develop completely new patterns of joint moments; rather, it was sufficient to retune the current moment patterns to account for new segmental properties and thus retain the internal timing characteristics.     

Early upper-extremity prosthetic fit in patients with burns

Patients with upper-extremity amputations necessitated by burn injury have frequently faced delays in prosthetic fit. At the Regional Medical Center, Memphis, Tennessee, seven patients required amputations because of burns. These injuries were electrical in four cases, thermal and crush in one case, thermal in one case, and steam and crush in one case. Five patients had below-elbow amputations, one had a bilateral below-elbow amputation, and one had a bilateral above-elbow amputation. All patients were fitted with prostheses within 30 days of the last definitive surgery on the amputated extremity. All patients continued to wear a prosthesis and no patient exhibited skin breakdown. Patients returned to independence with self care within 2 weeks and to preamputation activities within an average of 2.5 months.     

Sprint kinematics of athletes with lower-limb amputations.

OBJECTIVE: To determine and compare the kinematics of the sound and prosthetic limb in five of the world's best unilateral amputee sprinters. SUBJECTS: Five men, all unilateral lower-limb amputee (one transfemoral, four transtibial) athletes. The individual with transfemoral amputation used a Endolite Hi-activity prosthesis incorporating a CaTech hydraulic swing and stance control unit, a Flex-Foot Modular III, and an ischial containment total contact socket. Those with transtibial amputations used prostheses incorporating a Flex-Foot Modular III and patellar tendon-bearing socket, with silicone sheath liner (Iceross) and lanyard suspension. DESIGN: Case series. Subjects were videotaped sprinting through a performance area. Sagittal plane lower-limb kinematics derived from manual digitization (at 50 Hz) of the video were determined for three sprint trials of the prosthetic and sound limb. Hip, knee, and ankle kinematics of each subject's sound and prosthetic limb were compared to highlight kinematic alterations resulting from the use of individual prostheses. Comparisons were also made with mean data from five able-bodied men who had similar sprinting ability. RESULTS: Sound limb hip and knee kinematics in all subjects with amputation were comparable to those in able-bodied subjects. The prosthetic knee of the transfemoral amputee athlete fully extended early in swing and remained so through stance. In the transtibial amputee athletes, as in able-bodied subjects, a pattern of stance flexion-extension was evident for both limbs. During stance, prosthetic ankle angles of the transtibial amputee subjects were similar to those of the sound side and those of able-bodied subjects. CONCLUSION: Prosthetic limb kinematics in transtibial amputee subjects were similar to those for the sound limb, and individuals achieved an "up-on-the-toes" gait typical of able-bodied sprinting. Kinematics for the prosthetic limb of the transfemoral amputee subject were more typical of those seen for walking. This resulted in a sprinting gait with large kinematic asymmetries between contralateral limbs.     

Osteocutaneous pedicle flap of the foot for salvage of below-knee amputation level after burn injury

Lower extremity amputations are occasionally required after high-voltage electric and deep thermal burns. The extensive loss of skin and soft tissue after these injuries may make it difficult to fashion below-knee amputation that will readily tolerate a prosthesis. We have found an osteocutaneous pedicle fillet flap of the foot useful in the salvage of below-knee amputation after severe burn injury. Three patients have undergone this procedure after burn injury, 1 with burn secondary to high-voltage electric injury and 2 after deep thermal burns. All became ambulatory with artificial prostheses. There were no postoperative infections and no need for further revisions. The osteocutaneous pedicle fillet flap of the foot has proven to be a reliable form of below-knee stump coverage in patients with extensive soft tissue necrosis after burn injury.     

Outcome of prosthetic management of bilateral lower-limb amputees.

This study was designed to evaluate the outcome in 41 bilateral lower-limb amputees admitted to an inpatient unit for prosthetic rehabilitation. Outcome measures were obtained using a simple activities of daily living score, the Frenchay Activities Index, mobility grading, and assessment of home adaptations. Though excellent success rates were obtained after completion of physiotherapy, the majority of the above-knee amputees had abandoned their prostheses by the time of review. Bilateral below-knee amputees, however, continued to do well regarding their prosthetic mobility, and prosthesis users were more independent in their activities of daily living. We believe that inpatient rehabilitation programmes for bilateral amputees are likely to prove more satisfactory than prolonged outpatient physiotherapy.     

Effects of renal insufficiency and hemodialysis on the pharmacokinetics of rofecoxib

Rofecoxib (VIOXX, Merck & Co., West Point, PA) is a COX-2-selective inhibitor that combines anti-inflammatory and analgesic efficacy with improved gastrointestinal (GI) safety. The present open-label study investigated the pharmacokinetics, safety, and tolerability of a single, oral dose of rofecoxib (50 mg) in patients with end-stage renal failure (creatinine clearance <5 mL/min/1.73 m(2)) requiring hemodialysis. Rofecoxib AUC(0-48 h), AUC(0- infinity), C(max), T(max), and t(1/2) obtained from renal failure patients on hemodialysis were not significantly different from those obtained from healthy subjects. With hemodialysis initiated 48 hours postdose, rofecoxib AUC(0-48 h) adjusted mean ratio (renal failure/healthy subjects) was 0.81, with a corresponding 90% confidence interval (CI; 0.66, 1.00). Hemodialysis per se had no clinically meaningful effect on rofecoxib pharmacokinetics: plasma rofecoxib concentration-time curves were virtually superimposable when hemodialysis was initiated at 4 or 48 hours following rofecoxib dosing, although mean rofecoxib C(max) was 18% lower during the former (325 versus 395 ng/mL; P = 0.014). Overall, rofecoxib was well tolerated in end-stage renal disease patients. In this study, end-stage renal disease and hemodialysis had little effect on rofecoxib pharmacokinetics. Although there are no clinical data to support the use of rofecoxib in patients with severe renal insufficiency (creatinine clearance, 5-30 mL/min/1.73 m(2)), these data suggest that dosage adjustment of rofecoxib is not needed for patients with impaired renal function.     

Ergometer modification for combined arm-leg use by lower extremity amputees in cardiovascular testing and training

A commercial arm-leg ergometer was adapted so that combined bilateral arm-single leg work could be performed by unilateral lower extremity amputees from their own wheelchairs. Three middle-aged to elderly unilateral amputees performed progressive discontinuous bilateral arm crank and combined bilateral arm-single leg cycle exercise tests on the same air-braked ergometer adapted for either form of ergometry. Select amputees may achieve greater peak oxygen uptakes (VO2), power outputs (PO), and heart rates (HR) during combined bilateral arm-single leg cycle testing versus bilateral arm crank testing. Following 14 weeks of combined arm-leg training on the modified ergometer, a 73-year-old above-knee amputee demonstrated peak VO2 and PO increases of 25% (+3.8 mL X kg-1 X min-1) and 33% (+25W) respectively. Combined arm-leg ergometry as described herein may activate the largest available muscle mass and elicit the greatest oxygen uptake during exercise testing. In addition this exercise modality may simultaneously condition the arms and leg, providing functional gains in both wheelchair propulsion and prosthetic ambulation.     

Prevalence of risk factors predisposing to foot problems in patients on hemodialysis.

A disturbingly high prevalence of single or bilateral lower extremity amputations in our program prompted us to conduct a study to identify the prevalence of risk factors that predispose patients on hemodialysis (HD) to foot problems. The study consisted of a one-time assessment of subjects' risk for and actual prevalence of amputation. The sample consisted of 232 subjects--56% male, 44% female. Ages ranged from 21-91 years, mean age 65.1 and median age 69 years. The most common comorbidities were hypertension (75%), coronary artery disease (50%), diabetes (42.2%), hyperlipidemia (34.9%), and peripheral vascular disease (27.2%), which are all established risk factors for peripheral arterial occlusive disease. Twenty-one percent of subjects were current smokers; 28% were former smokers. Nearly 13.4% of subjects had undergone amputations ranging from single toes to bilateral above knee amputations. Only 31% of subjects had both bilateral palpable pedal pulses present. Neuropathy, as evidenced by the inability to feel the application of monofilaments to 10 sites on each foot or the presence of symptoms, was present in 74.6% of subjects. Only 2.6% of subjects demonstrated comprehensive self-care behaviors (SCBs). With respect to subjects' ability for self-care, 75% of subjects had adequate vision, 60% adequate dexterity, and 55% adequate flexibility to perform self-care. Study findings confirmed impressions that patients are at considerable risk for foot complications. Implications for nursing practice include regular foot assessment, education for self-care, and referral to specialists when required.     

Rehabilitation considerations of prosthetic fittings for Kaposi's sarcoma amputees

Purpose: We report on cutaneous limb manifestations of Kaposi's sarcoma and the secondary infection of these lesions that necessitated five lower-limb amputations. Method: The cases are briefly described and prosthetic adaptations in respect to pressure, traction and sweating on the skin are considered. Results: All four patients ambulated initially; one lady died, the double amputee stopped walking owing to the excessive physical demand, and two patients ambulate freely. Conclusion: Special considerations to the cutaneous/prosthesis interface are necessary in order to provide these patients with optimal ambulatory ability.